2 include_once("../globals.php");
3 include_once("$srcdir/md5.js");
4 include_once("$srcdir/sql.inc");
5 require_once("$srcdir/classes/POSRef.class.php");
6 require_once("$srcdir/formdata.inc.php");
8 if ($_POST["mode"] == "facility")
10 sqlStatement("update facility set
11 name='" . formData('facility','P',true) . "',
12 phone='" . formData('phone','P',true) . "',
13 fax='" . formData('fax','P',true) . "',
14 street='" . formData('street','P',true) . "',
15 city='" . formData('city','P',true) . "',
16 state='" . formData('state','P',true) . "',
17 postal_code='" . formData('postal_code','P',true) . "',
18 country_code='" . formData('country_code','P',true) . "',
19 federal_ein='" . formData('federal_ein','P',true) . "',
20 service_location='" . formData('service_location','P',true) . "',
21 billing_location='" . formData('billing_location','P',true) . "',
22 accepts_assignment='". formData('accepts_assignment','P',true) . "',
23 pos_code='" . formData('pos_code','P',true) . "',
24 domain_identifier='" . formData('domain_identifier','P',true) . "',
25 facility_npi='" . formData('facility_npi','P',true) . "',
26 attn='" . formData('attn','P',true) . "'
27 where id='" . formData('fid','P',true) . "'");
30 if (isset($_GET["fid"])) {
31 $my_fid = $_GET["fid"];
34 if (isset($_POST["fid"])) {
35 $my_fid = $_POST["fid"];
42 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
45 <body
class="body_top">
47 <span
class="title"><?php
xl('Edit Facility Information','e'); ?
></span
>
49 <form name
='facility' method
='post' action
="facility_admin.php">
50 <input type
=hidden name
=mode value
="facility">
51 <input type
=hidden name
=fid value
="<?php echo $my_fid;?>">
52 <?php
$facility = sqlQuery("select * from facility where id='$my_fid'"); ?
>
54 <table border
=0 cellpadding
=0 cellspacing
=0>
56 <td width
='24'><span
class='text'><?php
xl('Name','e'); ?
>: </span
></td
>
57 <td width
='120'><input type
='entry' name
='facility' size
='20' value
='<?php echo htmlspecialchars($facility['name
'], ENT_QUOTES) ?>'></td
>
58 <td rowspan
='10' width
='15'></td
>
59 <td
><span
class='text'><?php
xl('Phone','e'); ?
> <?php
xl('as','e'); ?
> (000) 000-0000:</span
></td
>
60 <td width
='210'><input type
='entry' name
='phone' size
='20' value
='<?php echo htmlspecialchars($facility['phone
'], ENT_QUOTES) ?>'></td
>
65 <td
><span
class='text'><?php
xl('Fax','e'); ?
> <?php
xl('as','e'); ?
> (000) 000-0000:</span
></td
>
66 <td width
='210'><input type
='entry' name
='fax' size
='20' value
='<?php echo htmlspecialchars($facility['fax
'], ENT_QUOTES) ?>'></td
>
69 <td
><span
class=text
><?php
xl('Address','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=street value
="<?php echo htmlspecialchars($facility["street
"], ENT_QUOTES) ?>"></td
>
70 <td
><span
class=text
><?php
xl('City','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=city value
="<?php echo htmlspecialchars($facility{"city
"}, ENT_QUOTES) ?>"></td
>
73 <td
><span
class=text
><?php
xl('State','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=state value
="<?php echo htmlspecialchars($facility{"state
"}, ENT_QUOTES) ?>"></td
>
74 <td
><span
class=text
><?php
xl('Zip Code','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=postal_code value
="<?php echo htmlspecialchars($facility{"postal_code
"}, ENT_QUOTES) ?>"></td
>
77 <td
><span
class=text
><?php
xl('Country','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=country_code value
="<?php echo htmlspecialchars($facility{"country_code
"}, ENT_QUOTES) ?>"></td
>
78 <td
><span
class=text
><?php
xl('Federal EIN','e'); ?
>: </span
></td
><td
><input type
=entry size
=20 name
=federal_ein value
="<?php echo htmlspecialchars($facility{"federal_ein
"}, ENT_QUOTES) ?>"></td
>
81 <td
> 
;</td
><td
> 
;</td
>
82 <td width
="21"><span
class=text
><?
php ($GLOBALS['simplified_demographics'] ?
xl('Facility Code','e') : xl('Facility NPI','e')); ?
>:
83 </span
></td
><td
><input type
=entry size
=20 name
=facility_npi value
="<?php echo htmlspecialchars($facility{"facility_npi
"}, ENT_QUOTES) ?>"></td
>
86 <td
><span
class='text'><?php
xl('Billing Location','e'); ?
>: </span
></td
>
87 <td
><input type
='checkbox' name
='billing_location' value
='1' <?php
if ($facility['billing_location'] == 1) echo 'checked'; ?
>></td
>
88 <td rowspan
='2'><span
class='text'><?php
xl('Accepts Assignment','e'); ?
><br
>(<?php
xl('only if billing location','e'); ?
>): </span
></td
>
89 <td
><input type
='checkbox' name
='accepts_assignment' value
='1' <?php
if ($facility['accepts_assignment'] == 1) echo 'checked'; ?
>></td
>
92 <td
><span
class='text'><?php
xl('Service Location','e'); ?
>: </span
></td
>
93 <td
><input type
='checkbox' name
='service_location' value
='1' <?php
if ($facility['service_location'] == 1) echo 'checked'; ?
>></td
>
97 <td
><span
class=text
><?php
xl('POS Code','e'); ?
>: </span
></td
>
99 <select name
="pos_code">
103 foreach ($pc->get_pos_ref() as $pos) {
104 echo "<option value=\"" . $pos["code"] . "\" ";
105 if ($facility['pos_code'] == $pos['code']) {
108 echo ">" . $pos['code'] . ": ". $pos['title'];
117 <td
><span
class="text"><?php
xl('Billing Attn','e'); ?
>:</span
></td
>
118 <td colspan
="4"><input type
="text" name
="attn" size
="45" value
="<?php echo htmlspecialchars($facility['attn'], ENT_QUOTES) ?>"></td
>
121 <td
><span
class="text"><?php
xl('CLIA Number','e'); ?
>:</span
></td
>
122 <td colspan
="4"><input type
="text" name
="domain_identifier" size
="45" value
="<?php echo htmlspecialchars($facility['domain_identifier'], ENT_QUOTES) ?>"></td
>
125 <td
> 
;</td
><td
> 
;</td
>
126 <td
> 
;</td
><td
><br
><br
><input type
="submit" value
=<?php
xl('Update Info','e'); ?
>> 
; 
; 
;<a href
="facilities.php" class=link_submit
>[<?php
xl('Back','e'); ?
>]</font
></a
></td
>